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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7� (Complete in Triplicate) Permit No..7_._�._ _......__. Date Issued- __________________________________________________---.-- t This Permit Expires 1 Year From Date Issued Application is hereby made to the San JoaquiXocal Health`District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Reguldtions: � 3 J08 ADDRESS/LOCATION._: ------------------------------------------� CL fJ_ E - -s- - C NUSTRA - �� l7 Owner's Name. ' !_lL��, ---------------Phone.----------- - _... -------- - Address - "' a�. � -- Ci -----'----------Zip------� --j--------- d: �r l Contractor's Name_______ ___________ - __________--------------------------------License # �___� Phone_-. y Installationwill serve: i. Residence,;; Apartment.House ❑ Commercial ❑ 4iler Court❑ K ' s 4 Motel ❑ Other----------------- ----------- ------?- Number of living units:._:'___:.___-_Number of_bedroams _:___Garbage Grinder- L�t Side- 7®.f ._ l' _...' _'Z .__. _ ---- --- ---� t _____ Characterofsoil to a de th of 3 feet: Sand •Silt Clay Peat Sand lti r _ _ Private Water Supply: Public System 'and name______________ __ F__ p ❑ ❑ Y ❑ ❑ y oarr',2z—Clay-Loam ❑ �. Hard arD<� Adobe:W Fill Material.-...........If yes, type--- ----- .---_- ,-- gw-,7rl t {Plot plan, showing size of lot, location of system:-in relation to wells, buildings, etc. md.st be place-d•on i-e'ver.se side.) NEW INSTALLATLON? No( septic tank or seepage pit permitted if public sewer is available wit infeet,] r ,. .�� PACKAGE TREATMENT [ ]` ASEPTIC TANK :___ :__ ____ _L1. UP! Depth's ____._. J . P y �' T e.. i -_�:'Mettarial � No�.Cotrl a, -- -r Ca acit -ll_ t' YP - -- -- p ariientst�` a r r ! Distance to riearest: Well-6_G>.'"_..___._.-.-- Foundation.f��_--.__----.-K;Pro'p. Cane.- t_�.s. . .A LEACHING LINE P<-, No. of Lines -----Length of ea.c line.__-- ----------- --_Total Length ------� ----------Vfi"_:---------_-� : _.! 'D' Box _____.._Type Filter Materiall- -. _____-___Depth Filter Material.-.- - -_ _- t { = Prape'rty.: ine:, _ ' , �" 'a`y I Distanceggto nearest: WE:11 ��-`r--..Number_ndation-_=________ � i SEEPAGE PIT _ Deptlr.T_�_Dlameter. -_ Rock Filled .aYes~❑••,-_No Water Table Depth--,__.---------------------------------------------------Rock Size---7 w� --- Distance to nearest: Well.-.1 --------------------------Foundation.----- ----_.Prop. Line.--_-'-_ -.--_'__ j REPAIR/ADDITION (Prev. Sanitation Permit t-__-_Date------------------- _------ Septic Tank (Specify Requirements]________________ --- - ------------------------------------------------------------- - tt Disposal Field (Specify Requirements)---------------------- ---------------------- ------------------------------=------------=--------------------- ---------------------- ---- ---------------------------------- =-: - f. ---------------------------------------------------------------------------------------------- ------- -------------------------- (Draw existing.and_require&ad4jtian on reverse side) hereby certify that I have prepared this application and thdt the work will be done-in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following.- "I ollowing:"I certify thatin the erformance of the work for which this-permit'is issued, I shall not employ any person in such manner as _ to beco subiect to Workman's. pensation. laws of California." Signed-- {_ J F . BY--------------- --------------- --- -------------- ------ l --........Title. ZAd- --�---- ---- ------------ -------.._ ----------- ---- (if other than owner) FOR DEPARTMENT SE ONLY APPLICATION ACCEPTED BY------------------- '_ ----- -- DATE -.-- ------- DIVISION OF LAND NUMBER--------- --- ------- --------------- ---DATE -- ----- - --- --- ' ADDITIONAL COMMENTS------------------- ---------- ------------------------------------------- ------- --------- - ------ -------------------- ---------------11- -------------- ------- --------------------- ------------------- -----------------------------------------------------------=----------------- -----------: -- ---------- -------------------------------------- ----------------------- ----------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------- ,_____.--------------- _______-___-___ _ _ ___-_______ ________________._________________._._....____.__________-___-____-_.__.__..__...___. Final Inspection by:- - ` = -- - = ==----------------------------------------------Date � 04 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M